The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

Search All Content

Displaying 1 - 20 of 2179 Results

On Patient Safety.

Save to Library

Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.

Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project.

Save to Library

Baluyot A, McNeill C, Wiers S. Patient Safety. 2022;4:18-25.

Transitions from hospital to skilled nursing facilities (SNF) remain a patient safety challenge. This quality improvement (QI) project included development of a structured handoff tool to decrease the wait time for receipt of controlled medications and intravenous (IV) antibiotics and time to medication administration. The project demonstrated significant improvements in both aims and can be replicated in other SNFs.

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

Save to Library

Sterling MR, Lau J, Rajan M, et al. J Am Geriatr Soc. 2022;Epub Dec 5.

Home healthcare is common among older adults, who are often vulnerable to patient safety events due to factors such as medical complexity. This cross-sectional study of 4,296 Medicare patients examined the relationship between receipt of home healthcare services, perceived gaps in care coordination, and preventable adverse outcomes. The researchers found that home healthcare was not associated with self-reported gaps in care coordination, but was associated with increases in self-reported preventable drug-drug interactions (but not ED visits or hospital admissions).

TeamSTEPPS Master Training Course.

Save to Library

Armstrong Institute for Patient Safety and Quality. January 31 and February 2, 2023.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

Detectability of medication errors with a STOPP/START-based medication review in older people prior to a potentially preventable drug-related hospital admission.

Save to Library

Sallevelt BTGM, Egberts TCG, Huibers CJA, et al. Drug Saf. 2022;45:1501-1516.

Adverse events, such as medication errors, are a major cause of hospital admissions. This retrospective study of a subset of OPERAM intervention patients who were readmitted with a potentially preventable drug-related admission (DRA) examined whether use of STOPP/START criteria during in-hospital medication review can identify medication errors prior to a potentially preventable DRA. Researchers found that medication errors identified at readmission could not be addressed by prior in-hospital medication reviews because the medication error occurred after the in-hospital review or because recommended medication regimen changes were not provided or not implemented.

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study.

Save to Library

Almqvist D, Norberg D, Larsson F, et al. Intensive Crit Care Nurs. 2022;74:103330.

Interhospital transfers pose a serious risk to patients. In this study, nurse anesthetists and intensive care nurses described strategies to ensure safe transport for patients who are intubated or who may require intubation. Strategies include clear and adequate communication between providers prior to transport, stabilizing and optimizing the patient’s condition, and ensuring that appropriate drugs and equipment are prepared and available.

In conversation with Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

Save to Library

Perspective on Safety December 14, 2022

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

Resilient Healthcare and the Safety-I and Safety-II Frameworks

Save to Library

Perspective on Safety December 14, 2022

This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.

Guidelines in Practice: prevention of unintentionally retained surgical items.

Save to Library

Cochran K. AORN J. 2022;116:427-440.

AORN revised its Guideline for prevention of unintentionally retained surgical items in late 2021. This article focuses on concepts and recommendations specific to counting procedures, reconciling discrepancies, technology, and education.

Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.

Save to Library

Rose SC, Ashari NA, Davies JM, et al. CJEM. 2022;24:695-701.

Debriefing is used to enhance individual and team communication and to facilitate real-time learning opportunities after a critical event. This study evaluated a charge nurse-facilitated clinical debriefing program used in Emergency Departments (EDs) in Alberta, Canada. Qualitative analyses identified several themes underscoring the impact of the debriefing program – the impacts on clinical practice and patient care, impacts on psychological safety and teamwork, stress management, and the emotional acknowledgement after critical events – and barriers to debriefing.

Guiding Principles to Achieve Continuity in Medication Management.

Save to Library

Department of Health and Aged Care. Canberra ACT: Commonwealth of Australia; 2022. ISBN 978-1-76007-471-5.

Originally published in 2005, these Guiding Principles outlines 10 guiding principles to support medication management as patients transfer from one care environment to another, both within one care setting (e.g., hospital) and between care settings (e.g., hospital to long term care). The Guiding Principles are person centered, equity, and coordination and collaboration.

Complexity and challenges of the clinical diagnosis and management of Long COVID.

Save to Library

O’Hare AM, Vig EK, Iwashyna TJ, et al. JAMA Netw Open. 2022;5:e2240332.

Long COVID-19 can be challenging to diagnose. Using electronic health record (EHR) data from patients receiving care in the Department of Veterans Affairs, this qualitative study explored the clinical diagnosis and management of long COVID symptoms. Two themes emerged – (1) diagnostic uncertainty about whether symptoms were due to long COVID, particularly given the absence of specific clinical markers and (2) care fragmentation and poor care coordination of post-COVID-19 care processes.

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial.

Save to Library

Johansen JS, Halvorsen KH, Svendsen K, et al. BMC Health Serv Res. 2022;22:1290.

Reducing unplanned hospital readmissions is a priority patient safety focus, and numerous interventions with hospital pharmacists have been developed. In this study, hospitalized adults aged 70 years and older were randomized to receive standard care or the IMMENSE intervention. The IMprove MEdicatioN Safety in the Elderly (IMMENSE) intervention is based on the integrated medicine management (IMM) model and consists of five steps, including medication reconciliation, patient counseling, and communication with the patient’s primary care provider. There was no significant difference in emergency department visits or readmissions between control and intervention within 12 months of the index hospital visit.

A longitudinal study on the impact of simulation on positive deviance through speaking up.

Save to Library

M. Violato E. Can J Respir Ther. 2022;58:137-142.

Healthcare trainees and junior clinicians are often reluctant to speak up about safety concerns. This qualitative study found that simulation training to enhance speaking up behaviors had lasting effects among advanced care paramedics and respiratory therapists as they moved from training into practice. Respondents highlighted the importance of experience for speaking up and the benefits of high-impact simulation training.

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

Save to Library

Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

Save to Library

Perspective on Safety November 16, 2022

Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

Save to Library

Starmer AJ, Spector ND, O'Toole JK, et al. J Hosp Med. 2023;18:5-14.

I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.

Criteria for the selection of paediatric patients susceptible to reconciliation error.

Save to Library

Iturgoyen Fuentes DP, Meneses Mangas C, Cuervas Mons Vendrell M. Eur J Hosp Pharm. 2022;Epub Sep 30.

Medication reconciliation at hospital admission has reduced medication errors, but less is known about the pediatric population, particularly which patients may benefit most from reconciliation. This retrospective study of pediatric patients who experienced at least one medication reconciliation error found children older than 5 years, taking 4 or more medications, or with neurological or onco-hematological conditions were at increased risk of errors. Prioritization of these populations may improve the effectiveness of medication reconciliation.

Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content.

Save to Library

Welch-Horan TB, Mullan PC, Momin Z, et al. Adv Simul (Lond). 2022;7:36.

The COVID-19 pandemic challenged the way healthcare teams functions. This article describes the implementation of a hospital-wide COVID-19 clinical event debriefing program, which encouraged care team members to reflect on what went well and what could be improved upon during care encounters with patients hospitalized with COVID-19. Qualitative synthesis of 31 debriefings highlighted issues with personal protective equipment, confusion around team roles, and the importance of both intra-team communication and situational awareness.

The debrief imperative: building teaming competencies and team effectiveness.

Save to Library

Tannenbaum SI, Greilich PE. BMJ Qual Saf. 2022;Epub Nov 2.

Team debriefing has the potential to inform improvements if done well. This article draws from educational practice to provide insights for enhancing the value of debriefing as a learning strategy in the clinical setting.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users